201. I’m back! European Hernia Update

This week, the topic of discussion was: 
-European Hernia Society
-Paris
-London
-Patients
-NHS
-Chronic Pain
-Sports Hernia
-Diastasis Recti
-Mesh Implant Illness

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh: +1-310-358-5020, info@beverlyhillsherniacenter.com.

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Transcript

Dr. Shirin Towfigh (00:00:07):
Hey everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. It’s been a minute, so I thank you all for joining me. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. I can be followed on X at herniadoc on Instagram at herniadoc. Many of you are joining me now live as a Facebook Live at Dr. Towfigh. And as you know, this can also be listened to as a podcast after the live session. The live session is purely intended to help answer your questions because I’m here for you and also many of you submit your questions ahead of time so I can answer them during the session. But priority is always for the people that are here as a live audience and also know this can be list to as a podcast attorney talk live and also on YouTube we have our YouTube channel and at some point I’m going to go through all of the top five or top 10 episodes we have, but it’s kind of interesting how certain topics are a little bit more important. I don’t think they’re as important. The ones that I think were really good episodes maybe sometimes are not always the most watched ones, but I’m always curious to look at the numbers to see what you all think is a valued episode. So let’s get started. I have not been on Hernia talk live for a while, mostly because I have been traveling and as many of you know who follow me on social media, especially on Instagram and Facebook, that I’ve been in Europe for several weeks now.

(00:02:09):
Every year we have the European Hernia Society meeting and I’m a really, really grateful member of their faculty. Usually I have been for this last, let’s see, six or seven years. So I get to give talks, I get to moderate sessions and this year we had three of our research presentations also available and presented at the meeting. So that was really cool. And this year the European Hernia Society meeting was in Paris. So as expected, it was also the most highly attended meeting because everyone wants to go to Paris and it’s an easy place for most people to kind of plan around. So it was a very, very busy meeting. I must say that it was a very well run meeting. Usually the European Hernia Society meeting is a bit smaller and a bit more not as user friendly as maybe many of the American Hernia Society meetings.

(00:03:16):
This one was really well done. It was three rooms that were running at all times, but the rooms were not really separated. They were all close to each other. So if you wanted to go from listen to one talk in one room and another talk in another room, it was available. Every single room was packed, which was really cool to see. We had a lot of young people this year. That’s really nice to see people that are trainees and young surgeons that are interested in hernias. We don’t really see that. We weren’t really seeing that back in the early two thousands. And so it’s really nice to see how much interest there is again, because it was Paris, the international component was really strong, so we had many of us Americans who were invited to give talks. We also had many from South America, a few from Canada, a fair amount from the Middle East and South Central Asia and Southeast Asia. So it was kind of nice to see in addition to Europe where the membership was really a European surgeons, there were a lot of non-Europeans at the meeting, which was really, really nice.

(00:04:40):
If you know anything about France, you know that they’re very into their strikes. So taxis decided to be on strike and the buses were on strike, so that was fun. And also they kind of liked their sports. So if you follow the soccer world, PSG, which is the Paris san team, won their European championships and the city went nuts and it was a little crazy because it seemed a little unsafe. The had a lot of what they called caso, which is basically breakers or looters, loiters that were taking advantage of the celebrations and there were some fires and some broken windows which were unnecessary and right around the time of the meeting, so I kind of showed up and the driver was like, ma’am, I don’t recommend you go out tonight, just stay at your hotel. And I said, why? You just show up in Paris.

(00:05:52):
First thing you want to do is go out and maybe have a nice dinner at a cafe. He’s like, no, it’s going to be mayhem. And he was absolutely right. It was crazy. The people were mostly having fun and celebrating because Paris creamed the other team, but at the same time it was a lot of drunk people and so it became a little bit unsafe towards the greater part of the evening. There were a lot of different great sessions at the meeting. There was many sessions on rectus diastasis. There’s a greater interest, especially with robotics in treating the rectus diastasis as part of a hernia repair. There was interest in the new meshes, so there’s more and more interest in these hybrid meshes and meshes that are more biologic. A lot of interest in synthetic absorbable meshes as opposed to synthetic non-absorbable or permanent meshes.

(00:06:57):
More data coming up in support of using ’em. There’s something called a mesh suture if you’re interested to know more about that. Dr. Gregory Ian, I may bring him in as a guest for him to explain his product. He’s a plastic surgeon in Chicago and he came up with something called a mesh suture and it’s basically an attempt to use suture to close your defect, but the suture is thicker and more mesh like than standard suture, and the goal is overall you’ll have less foreign body in you, but it’s non-absorbable and from a physics standpoint, it kind of makes sense to use a product, but from an inflammatory standpoint, maybe not. So we’re going to have Dr. Damian on as a guest in the near future to talk about abdominal wall reconstruction from a plastic surgeon standpoint, but also specifically about his mesh suture, which is a unique take. I would think that if you want to come up with a more advanced way of repairing, you would move away from mesh products and away from inflammatory products. He seems to embrace it but in a different way. It’s kind of interesting. There were multiple, multiple sessions on chronic pain that included research on chronic pain topics on reducing chronic pain and treating chronic pain for the groin and as well as for the abdominal wall, that was really good, a lot of great people talking about it.

(00:08:48):
This year we didn’t have as much sessions on the women’s hernias and also virtually no sessions on the mesh implant illness. Usually the topics are picked not only based on general interest but also the interest of the program chairs at the meeting. So that was kind of interesting to watch to see how it changes a little bit. There are some program chairs that are surgeons that are really into chronic pain or a mesh implant illness and have a whole in Manchester, we had a whole session just dedicated to mesh reaction. We did not have that this meeting and by the way, it was packed and wall to wall people back at the Manchester meeting to show you how much interest there is in patients. I’ll tell you something interesting. So as you know, this whole idea of potentially inflammatory or autoimmune reactions to implants including mesh, which I termed mesh implant illness, and we were the first to publish about it specifically with that term.

(00:10:13):
It used to be I could barely get the paper published because everyone kept poo-pooing the topic and saying, Towfigh is crazy talking about this stuff. We’ve never seen this before and yet and yet today I saw a patient who had a very large amount of mesh put in him just a big trauma reconstruction surgery, definitely not the type of patient you would expect to get mesh implant illness. We’ve discussed this before. They tend to be female, younger, very thin with maybe an autoimmune disorder or family history of autoimmune. This patient had none of those. However, he’s starting to get these red rashes and they’re itchy, which is not typical by the way of mesh and plant illness. They tend not to be itchy. He had these rashes and then he was sharing pictures of them with me where wherever the sun hit, he would be more red.

(00:11:19):
So hypersensitivity to the sun and then the areas where he itched a lot, it would welt like swollen welts of scarring, not scarring, but linear welts where he was itching. I tell you this because he went around to all of his friends and friends or friends who were doctors and he’s like, what do you think this is? And multiple doctors said You did have mesh in you. This may be a reaction to your mesh. Now no one would’ve said this five to 10 years ago, zero. I was one of very few maybe the only person talking about it. And for this patient to go to random doctors, which are friends of his not specialists, not hernia specialists, not even surgeons necessarily, and multiple people, doctors, friends of his friends of friends brought up mesh implant illness as a potential cause for his red rashes all over the body, the back, the neck, the arms, the hands, the thighs and for them to come up with that diagnosis I think is a win that implies that we’re getting the message out there.

(00:12:53):
The other thing I did in Paris was the hernia oral board exams. So as many of you knew know, I was granted and very honored by the European Board of Surgery, not the American Board of Surgery. I’m already board certified in the American Board of Surgery. I was granted an honorary European board of surgery in abdominal wall reconstruction, no in abdominal wall surgery and as a way of me paying back, I do volunteer my time as an oral boards examiner for the European Board of Surgery every year, and this happens typically before the European Hernia Society meeting, so I think we had 27 new surgeons who were board certified and passed the test. I think three did not pass for the European Board of Surgery, abdominal wall surgery certificate and it was fun. I had the hernia complex hernia question station and there’s I think six or seven stations, no more than that, maybe seven or eight stations and you have to pass the written boards first and then you go for the oral boards examination, which is what I was involved in. So that was kind of fun to do. Okay, I’m seeing a lot of questions being sent over, so let’s go through some of the questions live, which is why we’re here, and then I’ll tell you a bit more about my European escapades. It was awesome. Let’s see.

(00:14:39):
Did you attend any presentations on chronic pain post inguinal hernia? I did, but I did not hear anything new. It was mostly what you already know what I already knew about nothing groundbreaking, A lot of discussions about how to do the hernia repair correctly to reduce risk of pain, going over the different data as to who can get pain. The Swedish, sorry, the Danish hernia database did present their groundbreaking tenure follow-up their for their outcome. So that was kind of good. I’ll discuss that. It’s separate meeting, separate session. Let’s see. I’m interested in more on the mesh implant illness and correlation to length of time mesh was implanted before removal. I’m still struggling myself quite a lot, so we have not found a correlation, a direct correlation. In fact, there’s an inverse correlation. So the majority of patients wake up either immediately or within weeks to months with some type of symptom.

(00:15:58):
Certainly within the first six months, three to six months is when you expect to have symptoms. It is very, very, very uncommon to present two or more years after mesh implantation with symptoms and typically people who do present that late have something else going on and it’s not related to the mesh. So it’s the initial exposure, not the prolonged exposure that is the issue. I need to arrange a consultation with you. I need email. Your office already need mesh removal. Well, I did email. Okay, great. I’m happy to see you. When can you start to think there is a problem with the mesh? I’m five weeks post laparoscopic surgery and I’m still in a lot of pain. The surgeon is not helping much with why I’m in so much pain yet. Okay, so five weeks after, first of all, it depends on how much pain you’re in and what kind of pain, but laparoscopic hernia surgery should not be painful.

(00:16:55):
Most patients, their pain is improved after the first three days. It would be unusual for you to have significant pain at five weeks. So things that can go wrong are the mesh is incorrectly placed or folded. You have a fixation such as to that are too tight, that are too many, more than five is considered too many. If the mesh is placed too tight, then that could feel like armor on the inside and be very, very painful. You can’t stretch, for example, things like that or they just miss the hernia and you have a hernia recurrence. So if you’re in severe pain still at five weeks, get a second opinion. Number one, don’t go back to your surgeon and keep getting pushed down the line. You may want to get an MRI. You may have a fluid collection or a hematoma or seroma as well that can also cause pain in the area.

(00:17:58):
Okay, here’s a long question. Five plus months mysterious upper abdominal pain, still undiagnosed upper abdominal. Okay, I’ve done extensive cardiac and GI testing, EKG stress, echocardio cardiography laboratories, endoscopy, colonoscopy, three CAT scans of the abdomen, CT of the chest, MR angiogram, nuclear medicine HIA scan without injection. You need to have ejection fraction nuclear medicine gastric emptying study, full abdominal ultrasound, barium swallow GI study with no sign of reflex or hidal hernia. The only findings was non-obstructive kidney stones and the right stone was removed. Endoscopy said I have a small hial hernia but no explanation of my symptoms. Could the hiatal hernia be the culprit this whole time? So usually painful hial hernias are either large or you have a lot of what’s called reflux associated with it, but sounds like your endoscopy said it’s a small hidal hernia and your barium swallow GI study showed no sign of reflux.

(00:19:14):
So I would still pursue gi. They should have done biopsies of your esophagus to see if you have any evidence of what’s called esophagitis that can be painful. Also, an h pylori blood test to look for bacterial infection causing these symptoms could also be helpful and then treating it will help with your pain. The other options maybe have an abdominal wall hernia. It depends on where the pain is, if it’s in the midline and kind of between the belly button and your rib cage. Halfway between that could be a hernia that could cause your pain.

(00:19:57):
And I must say there’s this thing coming out. It’s currently available at Stanford under research investigation only where it’s a pain MRI PET scan. It’s a pain PET scan, so it’s a PET scan that involves an injection of an investigational drug that lights up wherever you have pain. So it could be helpful to do one of those studies where you get that done and then it says aha, it’s your esophagus or it’s your stomach or it’s your abdominal wall. Things like that. So if you want my advice, I’m happy to do what’s called it an online consultation. You can contact my office and we can tell you how to set up an online consultation. But yeah, it’s kind of one of those enigmas. Usually if it’s in the middle of the abdomen it’s due to a hernia or a hidal hernia. And then if it’s in the right upper quadrant, then it can also be related to the gallbladder. They should have done a HIA scan with the ejection fraction. Last comment. Sometimes it’s your pancreas and the pancreas can cause pain if let’s say there’s narrowing or something of the pancreatic duct and the MRCP can sometimes help with that. Okay, let’s see. I’m not having any excessive pain with my multiple mesh placements. Could it be a high level of skill of my surgeon? I love you.

(00:21:39):
Are you trolling me? I’m sure it’s the very high level of skill of your surgeon. Very good. Let’s see. Going back to the comment about the post laparoscopic surgery pain at five weeks, there are no tax or fixation. He said he just placed the mesh in place. Okay, well it depends on what kind of mesh was placed and to make sure the mesh was placed in flat. I’ll give you a story. As surgeons, we don’t usually operate with each other. So as a resident you operate with different attending surgeons in different specialties. So one resident can get experience from let’s say 20 different general surgeons once you graduate residency, unless you have a partner or a group that you work with, you don’t really operate with other surgeons so you don’t get to see how they operate.

(00:22:42):
I like to kind of go into different operating rooms and say, Hey, how are you doing? And see things, but I tend not to go into the hernia operations because I feel some of the surgeons may get all nervous in the room and they feel like I’m watching over them or whatever. So I have had experience there every so often to be in the room when they’re doing hernias and I’ll just say there are surgeries out there with great reputation for hernia repairs. Great. And I see it on videos too. And then you watch them operate and you’re like, okay, I would’ve not done that or that mesh is not the flattest. Now if you read the opera report, it’ll say that they made a wide dissection, they put the mesh in place, whatever, but where you’re there, you’re like that really wasn’t as wide of a dissection as I would’ve done and therefore the mesh is not as flat as it should be and this is a thin patient and I’m going to have to be worried if it were me, I would be worried that this patient would get chronic pain from a mesh being folded because the dissection was not adequate.

(00:23:58):
So my point is this your operating report, you’re now five weeks after surgery. The surgeon said I didn’t put the fixation in there, but did they do enough of a dissection to allow the mesh to laying flat before they were done and was it a mesh that does actually require fixation? These are all questions that I would have. So let’s say you do, if you ever choose to do a, what do you call it, like online consultation with me and you send me all your imaging and all of your reports and I read the report, it sounds like a perfectly done operation and then I see the imaging, I’m like, oh, your mesh is completely folded up and balled up in you. So imaging helps and it gives you a little bit more insight as to what the surgeon did than just the operative report itself.

(00:25:00):
Okay, given how common prostate cancer can be 15 to 20% lifetime risk and a high risk if family history and half requiring robotic arm surgery, number one, what is your recommendation in regards to tap EP with subsequent fibrosis in the extra peritoneal space? I’m concerned about robotic prostatectomy will be difficult with less nerve preservation and incomplete pelvic lymph node dissection. Number two, what are your thoughts on absorbable mesh in this situation to minimize fibrosis, but recurrence is an issue. Which one would you recommend if any? Okay, good question. So we’ve actually reviewed this with Dr. David Josephson who’s a very, very talented urologist who was a guest of mine early on I think two to three years ago on hernia talk live and I highly recommend you go back and listen to that. So we talked about prostatectomy and hernia surgery. So for those of you listening that don’t understand what a prostate has to do with a hernia, the prostatectomy involves going in, taking the bladder, cutting it off of the neck of the bladder, which is where the prostate is, taking out the prostate and then reattaching the bladder. So think of the bladder as your thyroid or your neck. So you’re going to chop off the head, which is a bladder. You can take out the neck, which is a prostate, and then you’re going to reso the bladder down to your shoulders basically, which is the rest of your urethra and all that. It’s a very delicate operation. Used to be done almost exclusively in open fashion. When I was a resident it was open surgery.

(00:27:03):
Now it’s done almost exclusively. I think 98% or something crazy like that in the United States are done robotically. Some still do it laparoscopically, very, very rare, rare because it’s very, very difficult to do so it’s either open or robotic surgery. About 97, 90 8% in the United States are done robotically. Now the same area where you go in to cut the bladder out, you also have to go to the left and right of the bladder to the groin where the lymph nodes are to sample lymph nodes because often these are done for a cancer, so you need to get lymph node dissections and then they do dissections all the way up the blood vessels. So when you go in for hernia surgery, if you’re doing the hernia surgery, either laparoscopically or robotically and infrequently, we do this for open the mesh, the dissection and the mesh is to the left and right of the bladder, which means sometimes, excuse me, I have to cough for some reason, which means sometimes what can happen is the same area of dissection for the bladder to be taken down to reach the prostate and for the lymph nodes to be sampled is the same exact space that a general surgeon uses for the hernia to be dissected open and then the match to be placed.

(00:28:54):
So there was a classic paper written during the time when they were doing open prostate surgery, which said the surgeon went in to do the prostate surgery open and by doing that it’s a scar in like a C-section type scar and they go down, they encountered the mesh and somewhere after that is going to be the bladder, but it was such a mess and there was so much scarring from the mesh, they couldn’t access the bladder and they couldn’t safely take out the prostate. So literally they had patients with prostate cancer that could not get prostate surgery and had to be treated with hormonal therapy, which is another way of treating prostate cancer if you don’t get surgery and that was a big deal. A hernia surgery was preventing people from having prostate surgery. That has not been shown to be a problem in the robotic age. We looked at our data at Cedar-Sinai at my hospital. I looked at all the people that had hernia surgery laparoscopically to see if any of them underwent prostate surgery and if they did, was it successful? Was it a lot of bleeding or what? No issues.

(00:30:16):
I then did the reverse. I looked at all the people that had prostate surgery and look to see if they were able to get hernia surgery. We know that if you’ve had prostate surgery, it’s preferable that the hernia surgery, it’s not in the same area so it’s open and not laparoscopic or robotic. However, I do offer it sometimes in some patients if it’s one or two or more years after their prostatectomy and I feel that the benefit of laparoscopic or robotic surgery is more than the benefit of open surgery, but it is a risk because you can injure the bladder when trying to do a hernia surgery. So you have to be very careful and very technically or really careful when you offer any type of laparoscopic or robotic angular hernia repair in someone who’s already had a prostatectomy. The reason why it is not an issue for the urologist to do a prostatectomy robotically in someone who’s already had an ankle or hernia repair is number one.

(00:31:30):
The access with the robot is from the abdomen up. So you basically take the bladder down. The bladder is usually not stuck to the mesh as much as you think and if it is you can just shave it down. I take mesh out all the time and I’ve never had to injure the bladder in doing so, which is a similar situation and then the lymph node dissection is done at or near the mesh and they can lift the mesh off or cut through the mesh without affecting the hernia repair and still do the lymph node dissection. So I’m not aware of that being a major problem. And so right now there is no recommendation to change the hernia repair based on the fact that you’re operating on a male who may need a prostate surgery in the future. I hope that’s clear for you.

(00:32:29):
The absorbable meshes that are out there actually cause just as much inflammation as does the synthetic mesh and I don’t recommend that you think it’s some fancy way to get around the problem, so I don’t recommend absorbable mesh. Here’s another question. Do you take traditional insurance? BlueShield, PPO? I live in Orange County. I definitely drive to Beverly Health for consult. We do accept private insurances that are PPOs as you have out of network benefits, but there’s always an out-of-pocket expense in addition to your insurance because we are out of network, just call my office and they’ll explain all of that to you. Here’s another one. I have a family member with a medical mystery, which means that makes me super happy, okay? They have been to multiple doctors, Chuck ER visits and hospital stays. Chuck no answers. The complete summary is here. Oh, you don’t expect me to open up this Google doc during her talk live?

(00:33:41):
I hope not. I would love to help your family member if you want to email my office and my nurse can take you through the process to figure out how I can help. Basically you would sign up for an online consultation or an in-person consultation and that gives me time to review all the documents and give you an idea of what I think is going on and I love medical mysteries. Okay, going back to the question about the correlation between time with mesh innu and mesh in playlists. Let’s see, I didn’t word that right. LOL I meant for example, mine wasn’t for eight plus years before I got to find you and Dr. Gibe. So I wondered if that been there had been any correlation to the mesh implant illness symptoms not subsiding as expected after surgery. I did great during the initial recovery. The surgery was in September, 2023, but now I have been having issues again for a while, but we were waiting because my belly button was an issue for Dr.

(00:34:51):
Gibe LOL and it’s still an issue unfortunately, but I have to say even with still struggling, I’m so very happy to have had your skilled hands save my life and extricate my liver from that dang mesh. Yes, this is true. So I thank you profusely every day I tell so many people to see you over other surveys. I appreciate that. Okay, so the question is if you’ve had mesh in you for a long time, is that, or let’s say you delay your mesh removal, is that detrimental? Not that we know of. So if you had mesh and plant illness, which I believe you had mesh kind of trapping your liver, so that wasn’t, I don’t think you had an implant illness per se, you had a bad complication from your mesh, but let’s talk about patients with mesh implant illness where your body is rejecting or reacting to the mesh In some patients, removal of the mesh will help reverse that situation because it’s the mesh that’s causing it and removing the mesh will then allow your body to go back to normal.

(00:36:06):
However, there are a handful of patients and we don’t know what percentage that is where they already had a tendency to becoming having an autoimmune problem or a reaction or allergy adding the mesh then woke up this tendency so to speak, and therefore removing the mesh doesn’t necessarily reverse the process because the process was going to happen potentially at some point anyway. It got woken up by the implant because the implant added an autoimmune or sparked some inflammatory process that you already had a tendency towards. Now that process has started and is moving forward. Removing the manage will not affect it because it’s now gone rampant. So that is a theory. We are definitely still in the learning times. We don’t know enough about mesh implant illness or any type of implant illness. She fell disease asia syndrome and our learning. And unfortunately for the patients that are out there, that means that you’re falling into this situation where we don’t know enough.

(00:37:28):
If so, we don’t know which patient falls into which category. So I always tell my patients there’s no test for mesh implant illness, we just have to remove it and see how you do. We can do a lot of testing before surgery to help tease out the people that may or may not benefit from the mesh removal by doing allergy testing, which as you know, it’s very often false and so that doesn’t usually help, but we still do it sometimes to just learn more. Then there’s full immunology workup and rheumatology workup and all that to see if there’s another diagnosis that was missing that may be explaining these problems. So then there’s these patients that don’t have mesh implant illness but actually have some type of chronic pain due to the mesh, which is more like your situation in those situations, removing the mesh will help.

(00:38:31):
However, if you’ve had chronic pain for a long time over year let’s say, then there is this problem where your body keeps sending messages of pain and getting it used to having pain, in which case removing the mesh and addressing the pain may not reset your brain and that’s where the pain medications and pain doctors get into helping because you can add ketamine and there’s all these other brain resetting things that they can do that can get rid of chronic pain. It’s very complicated. We’ve had multiple doctors in pain management field come and help us learn about this. The Dr. Samimi and Leilani who are really, really gifted pain doctors talked about this at one of the past hernia talk lives that we had and I recommend you watch that. So in that specific situation, there is a thought that the longer you allow your pain to continue unaddressed, the worse the outcome because your body gets used to it from a brain neuron synapse standpoint and so removing the trigger doesn’t necessarily reset what’s going on in your brain.

(00:40:03):
Okay, let’s see. Great show. You are a gifted surgeon. Thank you. I have testicular pain. My scrotum was hit and injured about one year ago, may of 2024. Initially the testicular pain was severe for a month. I could not sit for one minute. One month later the pain was less severe, but I could not sit again for one minute. Still about January, 2025, I could sit for about 10 minutes. Oh, this is terrible. About one month ago I applied lidocaine cream to the pain spot between my scrotum and my leg. It worked and my pain was reduced for a few days. What does this mean and what should I do next? I did do a colonoscopy in December, 2024 and after that procedure, my testicular pain and pain when sitting seems to be better, I can sit for 10 minutes instead of one minute. Is it possible that deep sedation and reduce my pain?

(00:41:05):
I feel I have recovered 50% but can never fully recover. What can I do to fully recover? What kind of treatment will be similar to having a deep sedation? Will taking benzodiazepines be a good treatment for my pain? Well, obviously I don’t know the full story, but it’s possible you had an injury. An injury caused scar tissue. Lemme rephrase this, you had injury. The injury caused bleeding and bleeding caused scar tissue causing pain. You could have had bruising of the nerves in that area if you were to see me and you’ve had a full urology workup, which shows everything is fine. You’ve got normal blood flow to your testicle and so on. I would inject your spermatic cord. So a spermatic cord block is one treatment and then a gentle nerve block. Definitely the spermatic cord block can be done by your urologist. I do it in the office.

(00:42:07):
I also do a genital nerve block in the office. Those are very helpful to help identify what’s good for you. If you feel that the lidocaine cream works, you can also add lidocaine patches and wrap the area of your spermatic cord and scrotum with lidocaine and see if that helps you. You can also try medications such as Gabapentin or Neurontin, Lyrica. These are all by prescription only and a urologist or pain doctor can help. Lastly, you can try creams. There’s arnica cream, there’s lakin cream. Arnica cream is anti-inflammatory cream. Voltarin is an anti-inflammatory cream. These are all over the counter. You may want to try supplements that help nerve pain. So super B complex is a good one for that. So I’m curious to know, for example, what kind of underwear do you wear? Do you wear tights, something tight to help support it or do you prefer it or is that too painful or you have to let it hang?

(00:43:14):
So that’s all indicative of what could be the problem. You can’t have a hernia, right? You can have a hernia and maybe the colonoscopy helps shift things around so you can have the hernia as much because maybe you were constipated or restraining in what they colonoscopy that helped you prefer to loose underwear. Okay, so if you prefer loose underwear, then that implies that the area is quite sensitive, so you may have a hernia imaging will help identify that and that could be the cause of downstream pain. So imaging can help with that. Those are all my thoughts on it. I hope that’s helpful.

(00:43:58):
Next question. At the European meetings, did you hear any presentations about athletic or pubalgia and sport hernias with any new revelations? Yes, so there was a whole session on sport hernias. The Europeans are really into their sport hernias. A lot of the major surgeons involved in the European hernia society are the doctors and surgeons for the major soccer teams. And as you know, soccer is one of the top sports injury needs in the groin. So much groin, abduction, abduction, and they do a lot of splits and they get kicked in the nuts and all that. So the Europeans love the sports hernia topics. So yes, there were multiple surgeons that provide their experiences. I would say the meeting that I went to in where was that?

(00:45:09):
Czech Republic and was it? I want to say yeah, I think it was the Manchester one. Those spent much more time on multidisciplinary approaches to sport attorneys and I’m trying to get one of the physical therapists from the UK to come on my team. He just won’t answer my emails. I don’t know why. I think they do WhatsApp. They don’t do much emails in the UK or in Europe in general. But anyway, they did talk about it. I did not learn anything new. It’s much the same, but I also go to a lot of these meetings and listen to a lot, so maybe it’s all the same to me, but it was a good overview of I think the advances in physical therapy are what’s newest from what I know is to get a good involvement of a good high quality physical therapist, which is of course very difficult to do.

(00:46:14):
Let’s see, I believe I have a large hernia with content that easily moves in and out of it constantly. Doctors I’ve seen say that I have an involuntary muscle movement and not a hernia. I have no muscle pain or soreness. How can I tell for a certain, which is the cause of the movement? I mean it depends on where the muscle movement is and you can try botoxing the muscle and see if those involuntary muscle movements go away. And if it does, then you have your answer. It’s kind of extreme thing to do. But if you’re given the runaround and no one can understand what’s going on, then that may be it. And there are multiple diseases that cause involuntary muscle movements. The most common one is Parkinson’s disease. I believe you’re on the younger side for that and that’s not your problem, but you can numb up that muscle or decrease its activity with some botulinum toxin injections and that can help figure things out because I believe you’ve been dealing with this for a very, very long time from what I recall.

(00:47:27):
Let’s see, going back to the question about length of time and mesh, the abdominal wall was separated too, and I was having what my doctor was calling fibromyalgia, but I felt like it was mesh related. I had a lot going on, unfortunately. Yeah, I do remember that. I might have to pony up for another virtual consult soon because yes, I’m still having a lot of nerve issues. I may think about ablation and muscle weakness no matter what I do. It’s frustrating and I’ll check that out. Thank you. Okay, so don’t jump into any conclusions, but yeah, happy to see you.

(00:48:04):
Okay, well what are the benefits of going to Europe for a surgical meeting is the food is really good, but also you get to experience the town of the meeting kind of like a local, so what they did was they really treated you nicely. We got a really nice dinner from the European Board of Surgery, great food, and we walked like, oh, we’ll just walk. I’m like, it’s like a 40 minute walk to the hotel. They’re like, yeah, but it’s so beautiful outside. And of course I had heels on, so I gave into peer pressure and I walked a beautiful 40 minutes to the hotel and it was just lovely to walk after dinner. The next night they had a faculty dinner on a boat, on the river sun and at night, as many of you know, Paris is called the city of Lights because the Eiffel Tower is beautifully lit and the Notre Dame is beautifully lit and the multiple bridges, the ports are very beautifully lit.

(00:49:19):
And you may have noticed a picture that I took from that top of one of those boats with the Eiffel Tower and the miniature Statue of Liberty, both in the same frame that was posted as part of this was I don’t need to talk live social media posts. That was a picture that I took that evening. It was really great. There wasn’t that much food. So after that we had to go get dinner. It was like 11 o’clock at night. We were hungry because they only had finger food and every single finger food was good, but it was literally half of the tip of my finger in the US we’re used to eating a little bit more than that for dinner. So we went out for dinner after that, which was great. The cafes were all open. And the following night there was a dinner at this really interesting museum of Foreign Arts, which was shut down for our session. And it was interesting. It was like an arcade from a century ago, if you can imagine what it would’ve been like. It was fun. It was fun. Again, there was finger food like this foot. So we went to a fantastic hole in the wall, French Bistro in the Sangerman district, which is a great foodie and hip and happening district and had some of the best food ever. And it’s so cheap relative to at least relative to the United States. Good food is really cheap there.

(00:51:05):
What else did we do? Yeah, it was like a lot of sessions. We had a women’s, oh, I mentioned there was a lot of young people at the meeting. There were a lot of women at this meeting. I was really impressed. Mostly younger, but yeah, a lot of women. I really, really liked that. Okay, more questions. S matic cord nerve block or genital nerve block seems a good idea. If it worked, how long will it last? And are the nerve blocks performed one time or a few times? So depends on who does it and what their protocol is. For me, I recommend getting a spermatic cord nerve block, giving you some time to recover from that. And then doing a genital nerve block to differentiate the benefits of each. If you get a benefit from it, it can be permanent or it could be hours or it could be days or it could be weeks. Everyone’s a little bit different depending on how you respond. You may be able to get more nerve blocks if you have more than a few hours of pain relief. And I would bring you back two or more weeks later and then do another nerve block for you and hopefully each time you get a nerve block, your pain will get better because we’re healing any direct trauma to any nerves in the area.

(00:52:18):
Is pro grip PLLA with polyester mesh a good one for lap repair without need for tax. But does PLLA cause lots of inflammation or fibrosis or do you have another recommended recommendation? Currently? Thank you. You are a great surgeon in communicator. Well, thank you very much. The program mesh I think is one of the best meshes on the market. It is polyester based, although they also are coming out with a polypropylene or they have a polypropylene based one. Certainly in Europe and I believe soon also are already in the United States. The pro grip mesh is a polyester flat mesh that’s a medium weight. And then there’s these little Velcro like graspers that allow it to kind of Velcro onto the muscle and then those absorb over time. So it’s great because those little velcros do not really cause significant inflammation or fibrosis just enough to allow the mesh to be fully integrated with the muscle.

(00:53:29):
And the mesh itself is very well made and has good options. So I do like it. I use it personally for all my robotic procedures as much as possible for the laparoscopic procedures. I’m not a fan of the program because I do tap TEP and it’s really hard to use that mesh in a small space that we have for te. But if you have a surgeon who does tap PP, then you have a little bit more space to allow the mesh to expand and not get stuck to everything. So very good mesh highly recommend. And the fact that it doesn’t need tax doesn’t mean doesn’t ever need tax. So for most hernias it does not need tax. If it’s for an abdominal wall and you’re able to close the defect, then you don’t need tax. And if it’s for a groin hernia and the hernias are not ginormous, you also do not need tax. But if the hernias are large, then you should use tax in addition. I believe not everyone believes that, but I believe. Okay.

(00:54:47):
Let’s see. For te, would you recommend the surgeon for te? What would you recommend the surgeon I was thinking of going to use as program with te. That’s fine for me, I think it’s too difficult to use program with tap. There are surgeons that do use PRO with tap, sometimes they use too small of a mesh because it’s just easier to use in tap and others do a good job of it. I’m not one of those. I think it’s not the easiest for tap and it really wasn’t made for the TAP technique. But if you have a surgeon who routinely uses Pro grip for tap and they have a good outcome, then it’s perfectly fine. It’s a very, very good mesh. I use the 3D Max for most of my laparoscopic tap mesh. And you also do not need to fixate that mesh for most attorneys.

(00:55:47):
Almost again, they’re on the larger side. Alright, well that was my France trip. I did take a trip to London as well and work with some surgeons there and I got to meet some doctors and surgeons there. And as you know, while I was in London, I had the opportunity to meet many of you in person and one of you very lovely even bought me flowers, which was awesome. I got fresh flowers in my hotel room for my whole stay there, which was very, very lovely. So thank you to those of you who contacted me. One of you flew in from another country to see me in London. That was really lovely and I knew some of you who came to see me as a follow-up while I was in London. So thank you very much for taking opportunity of that. And I may do this more often.

(00:56:45):
I feel like at some point it’s kind of cool to use the opportunity of going to other countries to also meet patients there. I obviously don’t have a license to practice in any of these countries, so I can’t be a doctor there, but I’m okay kind of hanging out and chitchatting and hearing your story and trying to give my advice and guidance to you while I’m in that country. So that experience of London was really, really good and I plan to do the same each time I go travel, I plan to announce it and if you guys want to meet with me, I’ll make my time available in between my fish chips. Let’s see. Here’s one about from Australia on Pro Australia has removed this from the Australian market. What are your views on this? The Prix program mesh was removed from the Australian market under the Section four one GL of the Therapeutic Goods Act 1989 because it was deemed to be misleading to a significant extent. This section allows for the immediate cancellation of medical device entries on the Australian Register of Therapeutic Goods. If there’s a breach of the act and the presentation of the device is misleading, the cancellation of the mesh device likely stem from concerns about its effectiveness or safety leading to a determination that its representation on the market was misleading.

(00:58:17):
Okay. Well I’m curious what that implies because if you could, let me rephrase this. If there’s any data that comes with that announcement as to what specifically they were misrepresenting, were they claiming that it’s superior to all of the meshes or that it has zero inflammation or something like that, then yeah, that’s not cool. More and more countries, including the European Commission, are requesting that the meshes show human data, ongoing human data and human data before it gets its approval. So maybe they do not have human data and that’s why Australia is doing the kibosh on program. You have my email actually, so send to me or you can direct message me, send it to me. I’d like to read specifically what about their claims they thought was misrepresentation. But that’s very, very great of you to note that. Thank you very much. Okay, that was it my friends.

(00:59:43):
We had our hour of her talk live. I love my q and as. I love talking with you all. Thank you very, very much for having such a wonderful series of questions, a lot of activity from you today. I hope that continues and I’ll see you again next week. Don’t forget to follow me for my typical patient education posts on Facebook and Instagram. Facebook is at Dr. Towfigh and Instagram is at hernia doc. I tend to report on meetings and more scientific stuff on X. So if you see me at a meeting or I know what I’m learning, follow me on X at hernia doc and don’t forget to subscribe to my YouTube channel at Hernia Doc. And if you prefer podcast to listen to me on as a podcast. Thank you. Share to whatever you like to do. See you all next week. And remember, it’s not just a hernia.